Emergency department (ED) capacity management has far-reaching implications for health and health system functionality. Overcrowded EDs can delay care, increase patient mortality, and lead to patient dissatisfaction.
Meanwhile, underutilized EDs can lead to waste, particularly in a health system already short on providers. In response, some health systems reduce ED capacity as a cost-containment strategy. While the Department of Veteran Affairs (VA) has not adopted this practice, there has been a significant shift towards Veterans utilizing non-VA community ED care, carrying the risk that Veterans leave the VA system altogether. This has led to ballooning financial costs for the VA, and comes with potentially negative impacts on Veteran health.
New Research
A recent paper by the Partnered Evidence-based Policy Resource Center (PEPReC) evaluated the impact of VA ED physician capacity on Veteran utilization of community care (CC) EDs. Specifically, the authors assessed whether increased VA ED physician capacity would shift demand away from CC EDs and ultimately brings Veteran back in-house for care.
Study Methods and Limitations
The authors used VA Corporate Data Warehouse data from over 100 VA EDs between 2014 and 2019, enriching the data with socioeconomic indicators from the American Community Survey and Area Health Resources Files. The independent variable was ED physician capacity, measured using the number of hours spent on patient encounters during an 8-hour clinic-day, while CC ED claims was the outcome variable.
The study used an instrumental variables approach. The two instruments were the proportion of weekday federal holidays and emergency clinician full-time equivalents. The models adjusted for Veteran demographics, insurance coverage, socioeconomic factors, and ED wait times. Sensitivity analyses confirmed the findings were robust, and the instrumental variables were validated for relevance and strength.
Worth noting, the evaluation was limited by reliance on claims data and how ED capacity was assessed by the VA. The findings lacked differentiation between Veteran ED and urgent care usage and cannot speak to how specific resources were allocated in clinics (e.g. number of facility beds). Lastly, the study period ended in 2019 and does not encapsulate significant operational changes post-2020. Overall, the evaluation findings may not be generalizable beyond the VA system.
Findings
The study found that increasing VA ED physician capacity reduced the use of CC ED services. When the authors used the proportion of weekday federal holidays as an instrument, they found that adding one eight-hour clinician shift per 10,000 enrollees reduced CC ED claims by 61 claims per month per 10,000 enrollees. When they used emergency clinician full-time equivalents as the instrument, they found that adding one eight-hour clinician shift per 10,000 enrollees led to a reduction of 48 claims per month per 10,000 enrollees.
Said another way, using the holiday-based model, every 1% increase in VA ED capacity led to a 1.42% decline in CC ED claims. Similarly, using the emergency clinician full-time equivalents model, a 1% capacity increase led to a 1.13% decrease in CC ED claims.
Importantly, VA facilities with the lowest ED capacity had significantly higher CC ED claims. Conversely, VA facilities with the highest ED capacity had the lowest CC ED claims. In short, this means that adding an 8-hour clinic day to facilities with the lowest ED capacity had the most impact on Veteran CC ED use.
Conclusion
These findings confirmed that enhancing VA ED capacity could meaningfully curb CC ED reliance. Similarly, keeping more ED care in-house has potential to increase use of other VA services, as many ED encounters require follow up care. As policymakers consider various options to address VA challenges, expanding VA ED capacity provides a proven method to help reintegrate Veterans into the VA system.
